The search for underlying causes of alcoholism and drug-addiction has delayed the growth of their diagnoses and treatment. often the emphasis and the debate are directed toward the etiology before the criteria for the addictions are established; the question asked is "why?" and then, "what?" rather than "what is it?" and, "why?". In reality, the reasons are not only unavailable at this time, but are relatively unimportant for the proper diagnosis and treatment of addiction.
The disease concept is an advancement toward a framework that can be used to define alcohol and drug addiction and enable scientific research hypotheses to be formed. The adaptive model is a recalcitrant retreat to explanations that have been inadequate for progress for a long time.
The article written by Dr. Bruce Alexander, "The Disease Adaptive Models of Addiction: A Framework Evaluation," in the Journal of Drug Issues Winter 1987, outlines an old and lively debate. The debate is whether the chicken or the egg came first. The disease concept versus the adaptive model for addictions is a centuries old dilemma. Historically, the concept for all diseases evolves from the adaptive model for the human condition. Alcohol and drug addiction as a disease is experiencing similar growing pains (Galizio and Maisto 1985; Jaffe 1985; Schuckitt 1978; Vaillant 1983).
The adaptive model originates from theories of causality in religion and morality and late nineteenth and early twentieth century psychology (James 1902). The religious concept of free will and willpower in disease has continued throughout centuries. People became ill because of a lack of moral character and true grit (Mendelson and Mello 1985; Milam 1978; Milam and Ketcham 1981). Mental illness only recently has enjoyed freedom from the concept of moral degeneracy. Certain forms of mental illness, particularly schizophrenia and manic-depressive illness, have been designated diseases only in the last fifty years. Prior to that time they were thought to be a possession by the devil or a loss of will and initiative (Goodwin and Guze 1984). This moral dilemma still applies to the addiction mode (Alcoholics Anonymous 1976). Alcoholism and other drug addictions are still viewed as a moral or psychological weakness for which a purging of the sins and strengthening of the ego of the individual are eradicating the causes of addiction.
The adaptive model is a framework that is reflective of an ancient conception. The adaptive model provides a framework from which to formulate hypotheses for further validation. Empirical validation of the adaptive model in other areas of medicine and psychiatry has resulted in the disease concept. The disease concept of alcohol and drug addiction is an advancement in a scientific and practical manner that is significant for understanding addiction. The disease concept was derived by a New York psychiatrist, Dr. William Silkworth, who formulated that alcoholism was an allergy of the body and an obsession of the mind (Alcoholics Anonymous 1976). The disease model is attractive not because of ideological theory but because it works. The adaptive model is intuitively appealing to the mind, but does not withstand scientific validation. The mind can just as intuitively consider that the earth is flat and is at the center of the universe as to the contrary that the earth is round and is part of a solar system around which it revolves. Scientific validation needs to demonstrate the fallacies of the intuitive mind. The disease model is deterministic, probablistic and mechanical as science itself. The scientific model has been an effective way for medicine to advance. To revert back to the adaptive model with philosophical suppositions and religious intonations is to go backwards and impede medical progress.
The disease concept of addiction purports a chemical vulnerability that constitutes a predisposition to alcoholism and perhaps drug addiction as has been for other mental illness (Goodwin 1985). The chemical interaction between drugs and the brain further induces neurochemical changes that enhance the addictive mode (Miller et al. 1987). Cocaine addiction is thought to affect the neurotransmitter dopamine through enhancement at the postsynaptic site (Dackis and Gold 1985). Genetic studies support that alcoholism is an inherited vulnerability through the genes (Bohman 1978; Cadoret and Gath 1978; Goodwin 1979 and 1985; Jones 1972).
The interaction between the drug or alcohol and the brain is responsible for the initiation of the addiction in the disease concept. Environmental stress, availability, attitudes and morality regarding alcohol and drugs are important factors that determine exposure to drugs and alcohol. The disease concept further states that economic, family, individual, psychological, psychiatric, physical, social and moral consequences ensue from addictive drug use. These can be in many stages of severity and intensity and affect the addict, as well as those around the addict. The important link in the disease concept is that the consequences result from, and do not cause, the addiction.
The adaptive model states the reverse. The economic, family, individual and social problems, stresses, lacks, evils and depravities lead to addictive use. The addictive use is to replace a failure in adult integration. The addict prior to the onset of addiction has failed to achieve maturity in the form of economic independence, self-reliance and responsibility towards others. Because of economic dependence, family breakdown, self-hate, and/or depression, the individual seeks and chooses to use drugs. The availability is determined by the environment, as well as the avidity with which the personality searches for drugs. The result is the addiction to drugs both licit and illicit along with other addictive behavior such as gambling, food and sex. The important ingredients to the equation in the adaptive model is that the addiction results from a lack of adult maturity through environmental problems. According to Dr. Alexander the individual seeks an identity of a drug addict which is preferable to that of admitting a failure in adult integration and maturity from the lack of economic, social and self-independence.
The disease model begins with the basic assumption that the etiological agent, alcohol or drugs, interacts with the susceptible host, a person with the genetic predisposition to initiate a disease process that qualifies for the definition of addiction (Miller 1987). Addiction is a preoccupation with the acquisition of alcohol or drugs, compulsive use in the face of adverse consequences and relapse to alcohol or drugs (Jaffe 1985). In the adaptive model, faulty upbringing and the lack of adult integration interact with drugs and alcohol to produce an addiction. The addictive mode that results improves the overall lot of the addict. The validity of this deduction does not match observations. Most addicts experience some deterioration in their personal and public lives from the preaddiction state. The diagnostic criteria for addiction require some impairment in lifestyle (Miller 1987; Miller et al. 1987; Schuckitt 1978). If the individual has experienced a significant improvement, it is difficult to diagnose addiction. The assumption is that preoccupation with, compulsive use of and persistent relapse to a particular drug will eventually preclude normal functioning in interpersonal relationships for the addict. Drugs and alcohol assume primary importance. other aspects of the addict's life become secondary and will suffer as a result (Dackis et al. 1987; Jellinek and Jolliffe 1940). An improvement in this regard in most instances is difficult to envision.
Addictive people are sick as is evident in the hundreds of medical, psychiatric and sociological complications from addiction (Lieber 1982; Schuckitt 1982). In New York City the single, largest risk factor for AIDS is intravenous drug use. AIDS is a medical complication that follows intravenous drug use that in many instances is secondary to addictive use. Also, the suicide rate among alcoholics and drug addicts is second to no other psychiatric illness (Litman et al. 1974; Martin et al. 1985). Depression, immaturity and personality difficulties as suggested by Dr. Alexander are lower on the list as causes of suicide.
Continued efforts toward the prevention of this disease is important. Just as the vaccinations for infectious agents are used commonly to prevent infectious diseases, preventative measures to treat the predisposition and exposure to drugs are important. Drug testing, drug education, law enforcement and education regarding alcohol and drugs are not an infringement on peoples rights as suggested by Dr. Alexander any more than are vaccinations. The federal government and states have mandated vaccinations during childhood to prevent unnecessary and wasteful deaths in individuals in the population. These same measures apply to alcohol and drug addiction equally as well.
Lastly, the disease concept relies heavily on personal responsibility. Recovery from alcoholics in the disease concept is through personal responsibility. The addict is responsible for his or her disease and the recovery as well. In the adaptive model the addict is consumed by forces outside that conspire to undermine his maturity. The addict is a victim within a network of forces which undermine maturity. All diseases begin with the concept that the individual is responsible for the disease. The diabetic has inherited the genes for diabetes and is responsible for the physical or genetic predisposition with which they were born. Also, the alcohol and drug addict is responsible for accepting treatment to be able to abstain from alcohol and drugs.
The disease model is popular today because it fits scientific inquiry and medical progress and works for the addict. The adaptive model still has appeal where knowledge is lacking or not accepted. The adaptive model is useful as a framework to form hypotheses. We hope that with continued research and accumulated knowledge, the true nature of the disease of alcohol and drug addiction will further emerge.
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By Norman S. Miller and Mark S. Gold
Norman S. Miller M.D., is director of Alcohol and Drug Abuse Treatment Service, NY Hospital-Cornell Medical Center in White Plains, NY. Mark S. Gold, M.D., is affiliated with Pair Oaks Hospital in Summit, NJ.MILLER
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Source: Journal of Drug Issues, Winter90, Vol. 20 Issue 1, p29, 7p